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Food Grade Driver Application Form

Driver Information

First Name
M.I.
Last Name
StreetAddress
CityStateZip Code
Social Security
Number
Date of Birth
 E-mail Address
Phone Number
Total Years of
Experience		Tank
Endorsement		HazardousMaterials
Endorsement
Yes No Yes No
List the years of experience operating each of the following equipment types:
Van
Tanker
Flatbed
Other
CDL License No.Issuing
State		Expiration

Have you ever been convicted of a felony?

Yes No
If yes, please explain:

Have you ever had your license suspended
or revoked?

Yes No
If yes, please explain:

Have you had any accidents in the last 3 years?

Yes No
If yes, please describe when, who was at fault,
and the damage amount:
Current Employer

Employer Name
Position Held
Start Date
End date
Salary
Street Address
CityStateZip Code
Phone Number
Contact

May we contact your current employer?

Yes No
Past Employers

Most recent employer (other than current)

Employer Name
Position Held
Start Date
End date
Final Salary
Street Address (if known)
CityStateZip Code
Phone Number
Contact

May we contact this employer?

Yes No

 

Next most recent employer

Employer Name
Position Held
Start Date
End date
Final Salary
Street Address (if known)
CityStateZip Code
Phone Number
Contact

May we contact this employer?

Yes No


Total Number of Previous Employers in the last 10 years:

As part of our consideration of your application, the DOT requires us to investigate your emplyoment background. As part of this investigation, we may obtain consumer reports about your DAC services. DAC is a consumer reporting agency.

Any decision we make not to hire you based on information contained in your consumer report will be our decision alone. DAC does not make any decisions concerning your employment with us and will not know the specific reasons why we may decide not to hire you.

In the event you are not hired based on information obtained in your consumer report, we will tell you. We'll also advise you of your right to obtain a free copy of the consumer report from DAC and your right to dispute accuracy of completeness of your report.

Your consent for us to obtain the report from DAC is required. Although you have a right to withhold your consent, we will not consider your application if you do. Do we have permission to obtain consumer reports about you from DAC?
( Please type the word 'Yes' or 'No' in space provided)




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